NEUROPSYCOLOGY |
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Q: Who are your patients?
Q: What sort of special clinical areas do you and your staff work with? ZEIFERT: We work with classic well-defined neurological disorders such as epilepsy, Parkinson's and brain injury. We also see people with other general medical disorders known to affect cognition. These might include disorders such as sleep apnea, rheumatoid disease, endocrine disorders and HIV. Also, we see adults and adolescents with various developmental disorders, including attention deficit disorder and learning disabilities. Another major component of our service is evaluation of people whose psychiatric conditions have an impact on their general function or medical condition. These could be pain patients or people suffering from significant depression. Q: Are there key questions you're expected to answer? ZEIFERT: The most frequent questions we are asked to address are whether cognitive dysfunction is present, and, if present, what will be its likely effect on a person's ability to function in the world. For example, we recently saw a patient with long-standing epilepsy who was being considered for organ transplant. The referral question concerned her ability to follow the complex medication regimen required post-surgery. We are also asked to determine the relative role of psychological factors in a patient's disability. This is a common question with such diverse groups as stroke, epilepsy and pain patients. Q: Do you see neuropsychology as definitive testing?
Q: When someone refers a patient, what do you do? ZEIFERT: We start with the referral question. What is the specific concern of the doctor or referral source? We obtain and review medical records. We do a clinical interview with the patient, and often with a significant other if the patient cannot provide an accurate description of his symptoms or problems. Then we administer neuropsychological tests. Some of these use paper and pencil, some use puzzles and others are administered by computer. These tests are sensitive to a wide range of skills within a specific cognitive domain. Generally, the examination lasts several hours, during which the patient is given tasks that assess IQ, attention, concentration, memory, learning, judgment, reasoning and language, as well as possible sensory and motor abilities. If specific difficulties emerge, we adjust or narrow our focus of inquiry. The tests are then interpreted with norms that take into account the patient's age and educational background. The patient's pattern of performance can then be compared with other patterns known to occur in certain types of illnesses and injuries. Because we obtain comprehensive information about the patient's cognition and information processing capacity and style, we can make recommendations about how to improve adaptation or compensate for deficits. The findings and recommendations are elucidated in a written report. Q: How many visits do patients typically make? ZEIFERT: Usually just one for the evaluation. If a patient has a short attention span or fatigues easily, we may spread the assessment over two or more sessions. We also usually provide a feedback session. Q: When do you refer patients?
WASSERSTEIN: My main use of neuropsychologists is to try to determine if there is a disease of the brain that is affecting the patient's thinking, as opposed to difficulties with memory, concentration and so on, resulting mainly from emotional causes. The second most common referral is for a person with a known medical or neurological disorder where I need more information about the extent and nature of the patient's impairment in order to make a treatment plan. I'd say that a substantial portion of the patients for whom I consider neuropsychological testing are people who appear well-functioning but who report difficulties concentrating and remembering things, even as they are successfully going about their jobs. In those situations, neuropsychological testing can be helpful either to show that their memories have declined or, more likely, that there is depression, anxiety or a related disorder. SOMMER: Neuropsych testing can often help pinpoint the patient's baseline cognitive status as a guide to start medications. We may also use such testing as a guide to help solve more practical problems, such as determining which areas of cognitive function are stronger than others. And the testing can often help patients' families find out what the problem means for them. I had a patient's wife ask me, "What should I be demanding of my husband? Should I be abstract with him? He used to be so abstract. Should I be more concrete with him?' Patients and families often want to know the cause of dementia, in which case neuropsych testing may be indicated. Q: How should you or the primary care physician decide whether the patient should be referred first to a psychologist, social worker or similar professional to evaluate whether the problem is psychosocial, and when the first referral should be for cognitive neuropsychological testing? WASSERSTEIN: Very often the patients' perspectives determine this decision. If patients are convinced that the problem is one of brain functioning rather than how their life is going or how their emotions are affecting their function, then they don't want counseling and the psychiatrist or psychologist also won't be able to help them. SOMMER: I think there are times when neuropsychological testing can be cost effective. Suppose a patient has no disturbance in mood and yet experiences a sudden change in behavior - such as suddenly deteriorated hygiene. Neuropsych testing can help us come to a consensus of dementia more quickly, and this can expedite treatment. WASSERSTEIN: Validating dementia with the aid of neuropsych testing can be especially useful in cases when the family or patient resists such a diagnosis. ZEIFERT: Often our testing can help patients themselves realize that a certain activity such as managing a checkbook or living alone is no longer a safe option. Q: If you rule out a neurological problem during a test, what's the next step? ZEIFERT: Often we are able to reassure the patients and their physicians that complaints are within the range of normal variability and unlikely to be the product of neurological disease. If cognitive symptoms appear due to depression or anxiety, we can facilitate a referral. We ask the referring physician if he or she prefers a particular specialist. If not, then we can suggest one. As I said earlier, feedback is provided to the physician through a written report and if requested, by phone. Patients are routinely invited to return for a feedback session. Q: Isn't another use of neuropsychology to determine if impaired individuals have recovered sufficiently to return to work? WASSERSTEIN: I think the issue with employment is sometimes driven more by motivation and energy level than by cognitive deficits. But in legal cases, neuropsych testing can be crucial in distinguishing cognitive deficits due to brain damage from secondary phenomena such as depression, anxiety, and compensation issues. ZEIFERT: Neuropsychology can be very helpful in evaluating employment capabilities. We have screened many patients for their readiness to resume employment after head injury, encephalitis, exacerbation of multiple sclerosis, removal of brain tumor, minor stroke, etc. Questions include whether a patient can return to work, and if so, when. Or, can the patient go back to the same position? We evaluate this by taking into account the person's work situation and job demands. For example, mild slowing of information processing might have devastating effects on the career of a high-level executive, but may have only relatively minor impact on someone with a routine, highly familiar position. Q: Do you perform ongoing evaluations? ZEIFERT: Yes. We would expect some recovery following stroke or traumatic brain injury, and we can do serial testing to document this improvement. This can be reassuring to patients and it can help in answering questions like ability to return to work. As Dr. Sommer mentioned, we're often asked to document cognitive changes. For example, with her patients, if we find mild cognitive impairment but it's not severe enough to meet a diagnosis of dementia, we might follow those patients annually to note possible changes. With early Alzheimer's, if she places the patient on memory-enhancing medications, we can monitor for effectiveness. Q: Can you describe how you would evaluate what someone might be capable of doing? ZEIFERT: Let's take an example of someone in a high-level job, a sales manager, a supervisor. These people must keep track of a number of different things happening at the same time. After a mild stroke, it's likely that they are not going to be as quick or efficient as before. We would do neuropsychological testing and look for possible deficits in these areas. We'd talk with the patient or family members about changes in behavior. We would educate the patient and family about recovery patterns and time lines, and we would recommend ways to adapt and compensate for deficits. Temporarily, this might mean a reduced workday to manage fatigue or a narrowing of work responsibilities to reduce multitask processing. If the patient wishes, we might discuss the treatment plan with colleagues or an employer. We want to have people return to their previous level of occupation if at all possible, but it may take some time. We recommend moderation so they can experience success as they recover. If not, this can lead to frustration, anxiety, and hopelessness. Luckily, depression is treatable and we would monitor for this. Q: There are some popular diagnoses, attention deficit disorder, for instance. Do you get a lot of requests to evaluate for this? ZEIFERT: Yes, we are frequently called by patients who are concerned that they have Attention Deficit Disorder and want us to confirm it. The popular literature has checklists for ADD which could fit most anyone. It can be a difficult diagnosis to make in adults because it tends to coexist with other disorders, such as depression. Sometimes we find it's not ADD, but bipolar disorder, a reaction to stress, or just the unique personality of the individual. SOMMER: This brings up a more general point. I think it's a mistake for patients to go directly to a consultant who has a very arcane group of tests for answering specific questions. The consultant can give a group of data points to provide better information to make a diagnosis. Saying "I have ADD and I think I'll go to see a neuropsychologist" is analogous to saying,"I have a headache, so I think I need to see a neurosurgeon." It is usually important for a patient to start by seeing a generalist, who will be able to interpret the data in the context of other information. Q: Is it advantageous being based in neurology, as opposed to your previous structure, which placed neuropsychology services in several departments? ZEIFERT: It makes much more sense this way. When we had a neuropsychologist on the acute rehab unit, he could not go upstairs to the Skilled Nursing Facility to assess a patient's readiness for more intensive rehab treatment. Nor was there a mechanism for him to follow rehab patients after discharge home. Now, we can evaluate a patient over the course of hospitalization regardless of the unit, or even on different admissions. We can take referrals from such diverse clinics as sleep, dermatology and kidney transplant. The same neuropsychologist can follow the patient regardless of referral source. And our records are all centralized in one place. With regard to our location in neurology, in most medical centers, neuropsychology is located in either neurology or psychiatry. Here, we see more patients with neurological disorders. Q: Can you think of particular cases where you really felt you made a difference? ZEIFERT: We don't have miracle cures in this field, but we can sometimes make a real difference in quality of life. I can recall a patient sent here from some distance who had been evaluated in different settings for years without a clear diagnosis. Her husband was frustrated and on the verge of litigation with their insurance company as his wife was shuttled back and forth from neurologists to psychiatrists. The patient was not yet 50. She had had an IQ of about 140, had a history of medication controlled epilepsy and then some years later became psychotic. She was referred for a neuropsychological evaluation here. When we looked at her records, we decided to admit her on the medical-psychiatry unit and she was evaluated by a multidisciplinary team of neurology, psychiatry and neuropsychology. We found she had a dementia and a secondary organic psychosis. There was no miracle, but the diagnosis was helpful to her husband, to the referring physicians who had been struggling and to the insurance company. Sometimes, the service can help people stop spinning their wheels. In another case, a boy in late adolescence had been fairly successfully treated for severe obsessive-compulsive disorder. Although his function improved, he felt depressed and hopeless about how poorly he continued to do in school. He considered himself stupid, but on testing we found he had an average to above-average IQ in non-verbal areas. However, he did have significant language problems, both processing what he heard and what he read. We recommended that he compensate by audiotaping information and playing it over and that the family work with the school to allow him more time for exams. We also recommended that he ask for clarification to see if what he heard was actually what was said. Realistically, we also recommended that he consider a non-academic career course and this was a relief to him. His family was highly educated and had naturally expected this of him but they were supportive and flexible. I think we were able to help restore his confidence and to reduce some to the uncertainty and ambiguity in his life. Sometimes, we can work with people as they make short-term plans after an injury. Recently, a professional woman came to us with a brain injury after a motor vehicle accident. Testing showed she had mild problems with concentration and slowness in thinking, as well as fatigue and a heightened sense of emotion. We saw her monthly, providing case management to sort out priorities and determine a strategy for returning to work. She chose to start by returning half time, tackling less complicated tasks initially. We also talked with her together with her husband about finding ways of dealing with her greater dependence on others, especially him. Ultimately, she returned to work full time and was able to function socially as before. Overall, I think it was of real value - being able to reassure her by predicting the course of her recovery, anticipating the next stage and allowing her to feel competent as she strategized and made choices about putting her life back together. SOMMER: Once I was asked to evaluate a 52-year-old man, an executive with a large company, who was afraid that he had Alzheimer's disease. He was the kind of high-powered person to whom you really didn't want to give that diagnosis. Although he did very well with the gross tests, there were some clear cognitive deficits. He received neuropsych testing when we first met him, and then again after six months, and we found he had deteriorated. We gave him a diagnosis of probable Alzheimer's very early on so he could face the situation squarely. It was a very sad outcome, but he was also able to make financial arrangements for his very young family.
WASSERSTEIN: If a definitive answer is reached for patients requiring a definite answer, they may be helped to deal with some emotional or social issues or - in the event that we find something wrong with the brain - to deal with the disorder and with its effect on how these patients can live their lives.
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COLUMNS
Chief of Staff
Fact File: Neuropsychology
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ZEIFERT: We receive referrals for a wide range of neurologic diagnoses from mild brain injury to Alzheimer's disease. We also see patients for whom the emotional or psychological aspect of their illness is a focus of referral. The service works with adolescents, adults and geriatric patients referred from within the Stanford health care system and from the community.
WASSERSTEIN: There is still plenty of room for interpretation even in the most objective of tests, such as MRI, but I think that realistically psychological tests produce a higher incidence of equivocal results than laboratory tests.
SOMMER: Sometimes, I'm called on to find help for a patient whose memory remains impaired even after we successfully treat depression. Then I can send the patient to a neuropsychologist to better define the remaining dementia. When I put patients on a memory- enhancing drug to slow the rate of memory-loss progression, I find neuropsychology testing gives us a practical way of assessing cognitive function. I also find the service helps me when I feel certain a patient is demented but I cannot document it with a mini-exam of mental state.